UGH.. Medicaid.Please help

I was wondering if anyone hear is on medicaid.. and what the process was.. how long it takes i just sent off for approval for step 1 and i guess there are 3 steps befor you can have surgery. I am so frustrated as i have been working on this for well over a year and half. I seem to be getting no where. I take one step forward and thrown back 2.. The surgery center i am trying to go to says that i have to have certain co-morbilities even though i have a bunch, its so frustrating to me. i'm not diabetic and i dont need joint replacement, what i do have is ...Sleep Apnea, hypothyroid, hypertention, high cholesteral, high blood pressure, insomnia, morbid obesity, depression and the list goes on and on. My doc says if i dont get the surgery i will end up with diabetes as it runs in my family as well as many other factors. please please help me i am desperate for answers... Michelle from Malaga, WA

Michelle, I have gone through the process. I've been trying for over 3 years. I was denied in 04 started the process again in 05. I went through steps one and two and am currently waiting to hear back on approval for three (the surgical stage). Anyway, it sounds like you have done what you need to do for now. The tricky thing about their new approval process is the requirements for medical neccessity are unclear. They say to be approved you must have diabetes, or have degenerative joint disease that is so advanced that you will need a joint replacement after you loose the weight. But, there is a third category of necessity I cannot remember how they describe it but it has to do with other rare life threatening conditions such as one i dont know the name of it is but it is a contiditon that makes you go blind. Anyway, this third area of necessity is the tricky one they dont lay out exactally what conditions will qualify you. All you can do is document all of your conditions and get a letter of medical necessity from your PCP. It sounds like you have done that so now just wait and see if they approve you for step 2. If you are denied please appeal!!! Your conditions seem very simular to mine so I would expect you to be approved for step two but you never know. As far as UW saying you dont qualify, dont worry about that. It seems to me that often times the surgeons staff have no idea what they are talking about when it comes to insurance issues, especially with medicaid. In any case you should start looking for providers for step 2 now before you are approved. They give you six months to get everything done and often it takes a couple of months just to find a provider that will accept medicaid or to get an appointment. You will need to see a registered dietician twice a month for six months, your pcp monthly for six months, a internist once for a physical to insure that you are healthy enough for surgery, a phychologist once to insure that you are mentally stable for surgery. Finding these providers is challenging it was the most difficult thing i have done as of yet, so get on it now don't wait. If you have questions feel free to email me at [email protected]. Good luck!!

Ok, now I have questions also. I am also on medicaid and am on the waiting list for the UW. I contacted medicaid and they told me that I first had to find a doctor then they would be the ones that did all the paperwork to get me approved. So now I am a little confused because you say that you can do it yourself. How do I go about starting the process then. My PCP says she will do anything I need her to do. But some help getting the ball going would be great? Once you have approval though then you only have a certain amount of time to get the surgery done? How do you do that if you cannot find a doctor? Please help me, maybe if all of us medicaid people get together and do this maybe then medicaid will make it so that we can get it done sooner. thank you

You do need a doctor. When I say you need documentation, I mean you need all of your medical conditions documented by physicians. This will be a vital part of what your PCP will use to prove medical necessity. Your doctor needs to send for approval for stage 1. This whole process often confuses the hell out of providers and they often screw things up. So the thing you need to do is stay on top of the process and make sure everything is getting done. The first step is to get your doctor to request the surgery. If you are approved that is stage one and you move directly to stage 2. Stage 2 is when you go to the dietician, psychologist, surgeon, internal med, etc. Medicaid will send you a letter explaining all of this. What I meant by getting on it now it simply to call around and find providers that will accept medicaid so that when you are approved for stage 2 you will know who to call to get an appointment. When you are approved for stage 2 you will have six months to get everything done. If you cannot find providers you arent looking hard enough. There is also a number on the back of your medical coupon and one on the letter they will send you that will supposidly help you find providers. They lead me to many who didnt work with this process but they were somewhat helpful. It takes time but it can be done. For example I was so persistant in trying to find someone to do my psych eval that finally my local mental health agency changed its policy to allow it. If you have providers lined up before you get your approval letter the process will be smooth. After you get the six month stage done you will gather all of your records and give them to your surgeon. You can have your surgeon request them from all providers but this may take weeks so I recommend hand delivering them. Then your surgeon will submitt all the documentation and request approval for stage 3 (the surgical stage). I can email you a copy of my letter if you wish. I will need your email address to send an attachment. I hope this is helpful. Sometimes i wonder if saying this just confuses people because you may not understand it untill you are in the middle of it. Anyway, email me if you have more questions [email protected]

Okay, I am a little freaked out right now. I contacted Dr. Rawlins and Dr. Bright. I actually spoke to Carol Pielli and she sent me a copy of 'Final Clinical Guidelines For Bariatric Surgery' she says Medicare/Medicaid requires for acceptance. I understand the stages, I guess, but my big problem is where to start? Who do I go to first? I have spoken at length with my PCP, but I am his first BS patient, and he is having to ask other doctors. The information he has gotten so far is that it is going to be a long, difficult process because I don't have diabetes, just insulin resistance. I am also scared that I wont be able to lose the required 5% of my weight which would be 14 pounds. If I am able to find a great nutritionist and have her work WITH me, I could do it. ***DEEP BREATH*** Here is my question, finally, where do I start? Who do I go to first to get the ball rolling? Some of these things I can figure out on my own, but a point in the right direction would be helpful as heck!!! OH!!! If any of you want a copy of the guideline info I received, I will gladly scan it and e-mail it you you!!! (I would need your personal e-mail I think) Thanks Y'all!!! Cindy in Wenatchee

Cindy I would love a copy of the guidelines. I am also trying to get the ball rolling. I have never gotten a copy of their guidelines that they use so that would be a great help. My problems isn't that I don't have the comorbities either it is finding a surgeon. I am on the waiting list at the UW but that could take years and I have went to two doctors in the last 4 yrs and both said I needed it then they quit taking medicaid, which really makes me mad but am going on. Here is my email address [email protected] Thank you

First - You call surgeon's offices to find one that accepts Medicaid. Start with the one you want, then next one, etc. Second - You make appt with the surgeon for consult, or info seminar, etc. They will do the paperwork and submit, tell you what you need to do.